objection used to be urged against this mode of operating, the fear
lest the thickened, brawny, and often ulcerated textures in the
neighbourhood of a diseased knee-joint, would not make a good covering.
This, however, is no longer a bugbear, as we see in cases of resection,
where the diseased joint alone is taken away, how very soon all swelling
and disease departs, once its cause is removed.

Mr. Syme's original operation was briefly as follows:--With an ordinary
amputating-knife make a lunated incision (Plate I. fig. 19) from one
condyle to the other, across the front of the joint, on a level with the
middle of the patella, divide the tissues down to the bones, and then
draw the flap upwards, then cut the quadriceps extensor immediately
above the patella. The point of the blade should then be pushed in at
one end of the wound, thrust behind the femur, and made to appear at the
other end; it should then be carried downwards (Plate III. fig. 5), so
as to make a flap from the calf of the leg, about six or eight inches in
length, in proportion to the thickness of the limb; the flap should then
be slightly retracted, and the knife carried round the bone a little
above the condyles to clear a way for the saw, which should be applied
so as to leave the section as horizontal as possible.

This method is now hardly ever used, as the following seems a much
better one:--

GRITTI'S[44] AMPUTATION.--In this two flaps are formed--an anterior long
one rectangular and a posterior short one. The condyles of the femur are
divided through their base, and the lower surface of patella is removed
by a small saw, and then the surfaces of bone approximated.

STOKES'S[45] MODIFICATION OF GRITTI'S AMPUTATION.--In this
"supracondyloid" amputation, the femur is sawn just above the condyles,
without going into the medullary canal. The anterior flap is oval, twice
as long as posterior, and the patella is brought up after denudation
against end of femur.

CARDEN'S AMPUTATION AT THE CONDYLES OF THE FEMUR.[46]--The operation
consists in reflecting a rounded or semi-oval flap of skin and fat from
the front of the knee-joint, dividing everything else straight down to
the bone, and sawing the bone slightly above the plane of the muscles,
thus forming a flat-faced stump, with a bonnet of integument to fall
over it.

The operator standing on the right side of the limb, seizes it between
his left forefinger and thumb at the spot selected for the base of the
flap, and enters (Plate II. fig. 8) the point of the knife close to his
finger, bringing it round through skin and fat below the patella to the
spot pressed by his thumb; then turning the edge downwards at a right
angle with the line of the limb, he passes it through to the spot where
it first entered, cutting outwards through everything behind the bone
(Plate IV. fig. 16). The flap is then reflected, and the remainder of
the soft parts divided straight down to the bone; the muscles are then
slightly cleared upwards, and I saw it applied.

I have ventured to make a slight change in the method of performing this
most excellent operation, for having found the posterior flap, as cut in
the method above described, rather scanty in the earlier cases in which
I have had occasion to perform it, after dissecting back the anterior
flap and cutting into the knee-joint, I shape a slightly convex
posterior flap of skin only, at least one and a half inches in length
in adult, and allow it to retract before dividing the muscles by a
circular cut to the bone, and have had every reason to be satisfied with
the change.

AMPUTATION OF THE THIGH.--Amputation of the thigh has been the favourite
battle-ground where flap and circular, antero-posterior and lateral,
long and short flaps, double, triple, and conical incisions, have
striven with each other; so were I to attempt to describe one quarter of
the various methods employed, I should need to rewrite the history of
Amputation.

It will suffice merely to describe the _best_ modes of amputating the
thigh through its lower, middle, and upper thirds respectively, and at
the hip-joint.

In one word, it may be stated that, with the exception of those
amputations performed through the lower third of the bone, the flap
method is to be preferred, and the flaps should in almost every case be
made by transfixion.

In the lower third, however, the flap method, though exceedingly easy,
and capable of very rapid performance, has certain defects; the chief of
these being the tendency which the muscular flaps (the necessary result
of transfixion) have to cause undue retraction, and hence protrusion of
the bone. This is seen specially in the hamstrings, which from the great
distance of their origin, and the purely longitudinal direction of their
fibres, retract to a very great extent, much more than the anterior
muscles can do from the pennate direction of their fibres, and the
manner in which they are mutually bound down to each other and to the
bone.

Even in this one position, the lower third of the thigh, the methods
that may be needed are various, and require separate notice;--for
operations here are extremely frequent from the frequency of strumous
disease of the knee-joint in our variable climate, and from the fact
that compound fractures or dislocations of the knee-joint so very often
necessitate amputation.

In cases where the skin over the patella is uninjured and available, the
operation by long anterior flap (either by Teale's method, or by Mr.
Spence's modification of it, which curiously is almost exactly similar
to the amputation of Benjamin Bell by a single flap) is suitable enough.
But, I believe, preferable to either of these is the operation of Mr.
Carden, already described. In cases where the knee-joint is injured, and
the skin over the patella unavailable, and yet where it is not necessary
to go higher up the limb, the modified circular amputation of Mr. Syme
will be found very suitable.

As it is in this lower third of the thigh that a very large proportion
of the cases requiring a long anterior flap is to be found, it affords
the best opportunity for comparing in their detail the three almost
similar plans of B. Bell, Teale, and Spence--after which Mr. Syme's
modified circular may be described.

BENJAMIN BELL'S FLAP OPERATION ABOVE THE KNEE (reported in his own
words, slightly abbreviated).--"When this operation is to be performed
above the knee, it may be done either with one or two flaps, but it will
commonly succeed best with one. The flap answers best on the fore part
of the thigh, for here there is a sufficiency of the parts for covering
the bones, and the matter passes more freely off than when the flap is
formed behind.... The extreme point of the flap should reach to the end
of the limb, unless the teguments are in any part diseased, in which
case it must terminate where the disease begins, and its base should be
where the bone is to be sawn. This will determine the length of the
flap, and we should be directed with respect to the breadth of it by the
circumference of the limb, for the diameter of a circle being somewhat
less than a third of its circumference, although a limb may not be
exactly circular, yet by attention to this we may ascertain with
sufficient exactness the size of a flap for covering a stump (Plate IV.
fig. 17). Thus a flap of four inches and a quarter in length will reach
completely across a stump whose circumference is twelve inches; but as
some allowance must be made for the quantity of skin and muscles that
may be saved on the opposite side of the limb, by cutting them in the
manner I have directed, and drawing them up before sawing the bone, and
as it is a point of importance to leave the limb as long as possible,
instead of four inches and a quarter, a limb of this size, when the
first incision is managed in this manner, will not require a flap longer
than three inches and a quarter, and so in proportion, according to the
size of the limb. The flap at its base should be as broad as the breadth
of the limb will permit, and should be continued nearly, although not
altogether, of the same breadth till within a little of its termination,
where it should be rounded off so as to correspond as exactly as may be
with the figure of the sore on the back part of the limb. This being
marked out, the surgeon, standing on the outside of the limb, should
push a straight double-edged knife with a sharp point to the depth of
the bone, by entering the point of it at the outside of the base of the
intended flap; and carrying the point close to the bone, it must here be
pushed through the teguments at the mark on the opposite side. The edge
of the knife must now be carried downwards in such a direction as to
form the flap, according to the figure marked out; and as it draws
toward the end, the edge of it should be somewhat raised from the bone,
so as to make the extremity of the flap thinner than the base, by which
it will apply with more neatness to the surface of the sore. The flap
being supported by an assistant, the teguments and muscles of the other
parts of the limb should, by one stroke of the knife, be cut down to
the bone, about an inch beneath where the bone is to be sawn; and the
muscles being separated to this height from the bone with the point of a
knife, the soft parts must all be supported with the leather retractors
till the bone is sawn," etc., arteries tied, and dressings applied.[47]

AMPUTATION OF THIGH BY RECTANGULAR FLAP--(Teale's).--I take the
opportunity here of describing fully, and as far as possible in his own
words, Mr. Teale's method of amputating, this being the situation where
his method is most frequently available. The same principle may be
applied to amputations at almost any other part of the body.

After advising the surgeon to mark out the proposed line of incision
with ink before the operation, he gives the following directions for
fixing the exact size of the flap:--"Supposing the amputation to take
place (Plate II. figs. 9, 10) at the lower part of the middle third of
the thigh, the circumference of the limb is to be measured at the point
where the bone is to be divided.[48] Assuming this to be sixteen inches,
the long flap is to have its length and breadth each equal to half the
circumference, namely, eight inches. Two longitudinal lines of this
extent are then traced on the limb, and are met at their lower points by
a transverse line of the same length. The inner longitudinal line should
be first traced in ink as near as practicable to the femoral vessels,
without including them within the range of the long flap. The outer
longitudinal line, which is somewhat posterior, is next marked eight
inches distant from the former and parallel to it. These two lines are
then joined by a transverse line of the same extent, which falls upon
the upper border of the patella, or upon some lower portion of this
bone. The short flap is indicated by a transverse line passing behind
the thigh, the length of this flap being one-fourth that of the long
one; or, assuming the circumference of the limb to be sixteen inches,
and the length of the long flap eight inches, the length of the short
flap is two inches. The operator begins by making the two lateral
incisions of the long flap through the _integuments only_. The
transverse incision of this flap, supposing it to run along the upper
edge of the patella, is made by a free sweep of the knife through the
skin and tendinous structures down to the femur. Should the lower
transverse line of the flap fall across the middle or lower part of the
patella, the transverse incision can extend through the skin only, which
must be dissected up as far as the upper border of the patella, at which
place the tendinous structures are to be cut direct to the thigh-bone.
The flap is completed by cutting the fleshy structures from below
upwards close to the bone. The posterior short flap, containing the
large vessels and nerves, is made by _one sweep_ of the knife down to
the bone, the soft parts being afterwards separated from the bone close
to the periosteum, as far upwards as the intended place of sawing.... In
adjusting the flaps, the long one is folded over the end of the bone,
and brought, by its transverse line, into union with the short flap, the
two corresponding free angles of each being first united by suture. One
or two additional stitches complete the transverse line of union. Care
is now required in arranging the two lateral lines of union. As the long
flap is folded upon itself so as to form a kind of pouch for the end of
the bone, it is requisite that it should be held in its folded state by
a point of suture on each side. Another stitch on each side secures the
lateral line of the short flap to